October 2012, Volume 4, Issue 10 - Torrance Memorial Medical Center

torrancememorial.org

October 2012, Volume 4, Issue 10 - Torrance Memorial Medical Center

VOLUME 4

ISSUE

10

OCTOBER

2012

MONTHLY

MEDICAL

STAFF

NEWSLETTER

ProgressNotes

TORRANCE MEMORIAL MEDICAL CENTER

this issue

The clash of clinical vs.

coverage/ payment concerns P.1

Medical Executive Approvals P.3

Medical Staff Calendar P.6

Roster Updates P.7

Continued...


Medical Executive Committee Approvals

The following items were presented and actions were approved at the September 11, 2012 Medical Executive Committee meeting:

Treasurer’s Report

A. July/August Treasurer’s Report

Medicine Department

A. Revised Cardiac Diagnosis Required Documentation Form

B. Revised Department of Medicine Rules & Regulations Appendices

Revisions:

Failure to Respond to Code 90

If the physician on call fails to respond to a Code 90 twice within a 3-month 6-month period, the physician will be removed

from the EKG Reading Panel. The physician may request to be reinstated on the EKG Reading Panel if they

have been complaint with the Code 90 Policy for 1 year from the date of removal from the EKG Reading Panel.

C. New Practice Prerogative Application Card for Allied Health Professional Nurse Practitioner – Cardiology Practice

D. Revised Clinical Privilege Application Card for Department of Medicine – Cardiovascular Disease/Cardiology

Revisions:

42.00 – Cardiovascular Disease/Cardiology Core

Privileges to admit, evaluate, diagnose, provide consultation, perform history and physical exam and treat patients of all

ages – except where specifically excluded from practice and except for these special procedures listed below – with

cardiovascular disease.

Privileges include, cardioversion, tilt table testing, insertion and management of central venous artery catheters, use of

thrombolytic agends, thoracentesis pericardiocentesis, echocardiography interpretation including, holter scanning,

treadmill and exercise testing including studies, and peripheral venous cutdown, and electrical cardioversion.

E. Revised Clinical Privilege Application Card for Department of Medicine – Neurology

Revisions:

Experience: Applicants must provide documentation of inpatient care for at least 50 patients as an attending physician

or resident during the past two years. Excludes applicants requesting only telemedicine privileges.

XX.XX – Telemedicine Reading of Intraoperative Neuromonitoring (IONM) – Intraoperative Evoked Potentials (SSEP),

Electromyography (EMG), Triggered EMG (tEMG), motor evoked potentials (MEP), Electro-encephalography (EEG)

and brainstem auditory evoked potentials (BAEP)

Qualifications: Training in this procedure must be verified by neurology residency or neurology subspecialty fellowship

Proctoring Requirements: 2

# cases required Init App: 50

# cases required Reapp: 50

F. Revised Clinical Privilege Application Card for Department of Medicine – Pulmonary Disease

Revisions:

XX.XX – Endobronchial Ultrasound Needle Aspiration/Biopsy

Qualifications: 1. Hold Pulmonary Core 49.00; 2. Documentation of Training Completion (Certification)

Proctoring Requirements: 0

# of cases required Init App: 0

# of cases required Reapp: 10

G. Revised Rules & Regulations for Department of Medicine, Article VI – Consultation

Revisions:

Consultation is specifically urged in the presence of the following conditions:

2. Complicated cardiac conditions myocardial infarction

Obstetrics and Gynecology Department

A. Division of Nursing Obstetrics Policy/Procedure entitled, “Scheduling of Inductions and Cesarean Sections”

B. Revised Clinical Privilege Application Card – Department of Obstetrics and Gynecology: Female Pelvic Medicine and

Reconstructive Surgery

Revisions:

Addition of Privilege 98.79: Da Vinci Surgical Platform and Assistant Da Vinci Surgical Platform.

Continued on page

2


Medical Executive Committee Approvals

The following items were presented and actions were approved at the September, 2012 Medical Executive Committee meeting:

Pediatric Department

A. Revised Clinical Privilege Application Card for Department of Pediatrics – Gastroenterology and Endoscopy

Revisions:

Deletion of 44.15-Liver Biopsy (includes Percutaneous and/or needle approach) 44.17-24 or 48-hour pH Interpretation

# of cases required Init App: 10 2

# of cases required Reapp:5 2

B. New Clinical Privilege Application Card for Department of Pediatrics – Pulmonary Disease

C. Revised Clinical Privilege Application Card for Department of Pediatrics – Critical Care

Revisions:

XX.XX – Basic Ventilator support management < 48 hours Burn unit only

# of cases required Reapp: 5 2

XX.XX – Pulmonary artery (Swan Ganz) catheters Burn unit only

Qualifications: 1. Documentation of completion of a Pediatric Critical Care Fellowship; 2. Documentation of training

during fellowship; or 3. Board Certified in Pediatric Critical Care

# of cases required Init App: 4 2

71.31 – Vasoactive Drug Drips Burn Unit only

71.32 – Invasive Monitoring Burn Unit only

Qualifications: 1. Documentation of completion of a Pediatric Critical Care Fellowship; 2. Documentation of training

during fellowship; or 3. Board Certified in Pediatric Critical Care

Bylaws Committee

A. Revised Medical Staff Services Policy/Procedure entitled, “Disaster Privileges”

B. Revised Medical Staff Services Policy/Procedure entitled, “Professional Practice Evaluation”

C. Revised Medical Staff General Rules and Regulations

Revisions:

Section C. MEDICAL RECORDS

6. Operative and Other Procedure Documentation Requirements (RC.02.01.03 EP5-7)

EP5: An operative or other high-risk procedure report shall be written or dictated upon completion of the operation or

other high-risk procedure and before the patient is transferred to the next level of care.

Note 1: The exception to this requirement occurs when an operative or other high-risk procedure progress note is

written immediately after the procedure in which case the full report can be written or dictated within 48 hours after

the operation or procedure.

Note 2: If the practitioner performing the operation or high-risk procedure accompanies the patient from the operating

room to the next unit or area of care, the report can be written or dictated in the new unit or area of care.

EP6: The operative or other high-risk procedure report includes the following information:

Name(s) of the licensed independent practitioner(s) who performed the procedure and his or her assistant(s)

2. The name of the procedure performed

3. A description of the procedure

4. Findings of the procedure

5. Any estimated blood loss

6. Any specimen(s) removed

7. The postoperative diagnosis

EP7: When a full operative or other high-risk procedure report cannot be entered immediately in to the patient’s

medical record after the operation or procedure, a progress note is entered in the medical record before the patient

is transferred to the next level of care. This progress note includes:

1. The name(s) of the primary surgeon(s) and his or her assistant(s)

2. The name of the procedure performed

3. A description of the procedure

4. Any estimated blood loss

5. Any specimen(s) removed

6. The postoperative diagnosis


Medical Executive Committee Approvals

The following items were presented and actions were approved at the September 11, 2012 Medical Executive Committee meeting:

The provisional diagnosis before the operative or other high-risk procedures shall be recorded. (RC.02.01.03 EP2)

An operative or other high-risk procedure progress note, as an abbreviated report, is entered in the medical record immediately

after the procedure. (RC.02.01.03 EP7)

The medical record contains the following postoperative information:

a. The patient’s vital signs and level of consciousness. During operative or other high risk procedures, including

those that require the administration of moderate or deep sedation or anesthesia, the patient’s oxygenation, ventilation,

and circulation are monitored continuously. The hospital assesses the patient’s physiological status immediately

after the operative or other high risk procedure and/or as the patient recovers from moderate or deep sedation

or anesthesia.

b. Any medications, including intravenous fluids and any administrative blood, blood products, and blood components.

c. Any anticipated events or complications (including blood transfusion reactions) and the management of those

events. (RC.02.01.03 EP8)

The full operative/procedure report shall be written or dictated and authenticated as soon as possible (48 hours) after

the procedure.

G. EMERGENCY DEPARTMENT CALL PANEL

By action of the Medical Executive Committee on September 12, 1995, all Active, Associate, Courtesy and Provisional

(where proctoring has been successfully completed), staff members will be required to provide emergency department

call coverage. This includes in-house coverage, when requested, by the physician on the ER Call Panel the day of the

request, not the day the patient was admitted to the hospital. Excluded from call coverage are Affiliate staff members,

Honorary staff members, Retired staff members and Provisional staff members (who have not completed their proctoring).

Required call will be assigned according to the physician’s primary specialty unless otherwise specified. Any

physician assigned for ER call coverage will also be required to provide coverage for patients admitted to the hospital

as requested by the attending physician. If the physician on ER Call or their designee is unavailable, the Department

Chief (of the concerned department) will be called upon to resolve the situation.

Credentials Committee – Approvals filed in Medical Staff Services – please see Toni Woodard.

Infection Control/P&T Committee

A. Formulary Review: DaTscan, Totect®, Oncaspar, Halaven, Voluven

B. Potassium IV Administration

C. Epidural Continuous and PCEA Infusion Orders

D. IV Guideline Changes

E. Adult Parenteral Nutrition Orders

Institutional Review Board – Approvals filed in Medical Staff Services – please see Yumi Lee.

Nominating Committee

Nominations for 2013 Medical Staff Officers

Secretary/Treasurer: Vinh Cam, M.D.

Assistant Chief of Staff: Eric Milefchik, M.D.

Chief of Staff: Thomas Simko, M.D.

Members-at-Large: John Abe, M.D., Garrett Matsunaga, M.D., Brian Miura, M.D.,

Alex Shen, M.D., Aileen Takahashi, M.D.


Medical Staff Calendar

October

Monday Tuesday Wednesday Thursday Friday

1 2

3

4

5

8:00a TCU Committee………..WT-C

12:30p Infection Control/P&T….WT-C

7:00a CV Review Conference.WT-D

12:30p CME Conference…..HCC 1&2

7:00a Breast Tumor Board...WT-Aud

7:30a Tumor Board………...WT-Aud

12:30p MSPI…………………….WT-D

7:00a Surgery Dept………...WT-Aud

8

9

10

11

12

7:30a IRB Committee…………WT-D

7:30a Physician Alignment.…..WT-B

12:30p Credentials………….…..WT-C

5:00p Professional Relations...WT-C

6:00p Medical Executive……..WT-D

7:00a Anesthesia PI………..WT-Aud

7:00a CV Review Conference.WT-D

12:30p CME Conference…..HCC 1&2

7:00a Breast Tumor Board...WT-Aud

7:30a Tumor Board………...WT-Aud

12:30p Medicine PI……………..WT-B

15

16

17

18

19

7:00a Cardiothoracic Surgery..WT-C

12:00p Burn & Wound………….WT-C

12:00p Radiology Dept……...WT-Aud

7:00a CV Review Conference.WT-D

7:00a Breast Tumor Board...WT-Aud

7:30a Tumor Board………...WT-Aud

9:00a Emergency Dept……….WT-D

12:30p Pediatric Dept………..WT-Aud

7:00a Vascular Medicine……..WT-C

7:00a Surgery Advisory……….WT-D

22

23

24

25

26

4:00p Bariatric Surgery……….WT-D

12:30p OB/GYN Dept………..WT-Aud

7:00a CV Review Conference.WT-D

12:00p General Staff……….HCC 1&2

12:30p Bioethics………………..WT-B

7:00a Breast Tumor Board...WT-Aud

7:30a Family Practice Dept…..WT-B

7:30a Tumor Board………...WT-Aud

12:30p Credentials……………..WT-C

12:30p Health Info. Mgmt……...WT-B

7:00a General Surgery………..WT-C

29 30 31

7:00a CV Review Conference.WT-D

CME CONFERENCES

Wednesdays, 12:30 pm

Health Conference Center

Torrance Memorial Medical Center is accredited by the Institute for

Medical Quality/California Medical Association (IMQ/CMA) to provide

continuing medical education for physicians.

Torrance Memorial Medical Center designates this live activity for a

maximum of 1 AMA PRA Category I credit TM . Physicians should claim

only the credit commensurate with the extent of their participation in

the activity.

This credit may also be applied to the CMA Certification in Continuing

Medical Education.

For up-to-the minute conference information call (310) 784-8776.

October 3, 2012

“Hepatitis A, B & C”

Sammy Saab, M.D.

UCLA School of Medicine

Commercial Support: Gilead

October 10, 2012

“Functional Bowel Diseases”

Christopher Chang, M.D.

UCLA School of Medicine

Commercial Support: None

October 17, 2012

NO CONFERENCE

October 24, 2012

NO CONFERENCE

October 31, 2012

NO CONFERENCE

November 7, 2012

“Ventilator-Associated Pneumonia”

Hidenobu Shigemitsu, M.D.

USC School of Medicine

Commercial Support: None

November 14, 2012

“Medication Safety”

Jody Jacobsen Wedret, Ph.D.

UCI Medical Center

Commercial Support: None

3


Welcome New Practitioners on Staff

Jean R. Allard, M.D.

Cardiothoracic Surgery

575 E. Hardy St., Ste. 322

Inglewood, CA 90301

Phone: (310) 671-0488

Fax: (310) 671-7618

Timothy S. Kristedja, M.D.

Oncology/Hematology

California Hematology Oncology Med Grp.

3440 Lomita Blvd., Ste. 250

Torrance, CA 90505

Phone: (310) 530-9763

Fax: (310) 784-1704

Rama E. Chandran, M.D.

Orthopedics

4477 West 118th St., Ste. 402

Hawthorne, CA 90250

Phone: (310) 644-1151

Fax: (310) 644-3115

Heidi A. Limkemann, M.D.

Hospitalist, Pulmonology, Internal Med

HealthCare Partners Hospitalists

3330 Lomita Blvd.—HCP 1st Floor

Torrance, CA 90505

Phone: (310) 784-8770

Fax: (310) 784-4991

Shaun E. Chandran, M.D.

Orthopedics

4477 West 118th St., Ste. 402

Hawthorne, CA 90250

Phone: (310) 644-1151

Fax: (310) 644-3115

William M. Luxford, M.D.

Otolaryngology

House Ear Clinic

2100 W. Third Street

Los Angeles, CA 90057

Phone: (213) 483-9930

Fax: (213) 484-5900

Stephanie Wei-Ying Chen, M.D.

Pediatrics/Internal Medicine

Palos Verdes Medical Group

550 Deep Valley Drive Ste. 319

Rolling Hills Estates, CA 90275

Phone: (310) 544-6858

Fax: (310) 544-6855

James S. Pratty, M.D.

Psychiatry, Addiction Medicine

21081 S. Western Ave., Ste. 250

Torrance, CA 90501

Phone: (310) 217-8877

Fax: (310) 224-5290

Genevieve L. Hasek, M.D.

Emergency Medicine

Torrance Emergency Physicians, Inc.

3330 Lomita Blvd.—Emergency Dept.

Torrance, CA 90505

Phone: (310) 325-9110

Fax: (310) 784-3789

Maria E. Rhoads-Baeza, M.D.

OB/GYN

20911 Earl St., Ste. 480

Torrance, CA 90503

Phone: (310) 370-7277

Fax: (310) 542-8893

Lily Honoris, M.D.

Hospitalist, Internal Medicine

Torrance Memorial Hospitalists Assoc.

3330 Lomita Blvd.—TMHA 1st Floor

Torrance, CA 90505

Phone: (310) 891-6623

Fax: (310) 891-6673

Houman Saedi, M.D.

Vascular Surgery

Association of South Bay Surgeons

23451 Madison St., Ste. 340

Torrance, CA 90505

Phone: (310) 373-6864

Fax: (310) 373-9547

4


Welcome New Practitioners on Staff

Yasmeen Shaw, M.D.

Hospitalist, Pulmonology, Critical Care

Internal Medicine

HealthCare Partners Hospitalists

3330 Lomita Blvd.—HCP 1st Floor

Torrance, CA 90505

Phone: (310) 784-8770

Fax: (310) 784-4991

Von A. Ta, M.D.

Hospitalist, Internal Medicine

Torrance Memorial Hospitalists Assoc.

3330 Lomita Blvd.—TMHA 1st Floor

Torrance, CA 90505

Phone: (310) 891-6623

Fax: (310) 891-6673

Peter B. Shin, M.D.

Family Practice

3440 Lomita Blvd., Ste. 427

Torrance, CA 90505

Phone: (310) 326-2161

Fax: (310) 534-5026

Khaled A. Tawansy, M.D.

Pediatric Ophthalmology

7447 N. Figueroa St. Ste. 200

Los Angeles, CA 90041

Phone: (323) 257-3937

Fax: (323) 257-3200

Physician Roster Updates

Change of Address/phone/fax:

Elaine Jones, M.D.

Fax: (310) 939-7861

Specialty: Internal Medicine

Sunil Rangappa, M.D.

325 N. Maple Dr., Ste. 5104

Beverly Hills, CA 90209

Phone: (310) 890-2364

Fax: (310) 366-4666

Specialty: Cardiology

Shirlene Jay, M.D.

3400 Lomita Blvd., Ste. 503

Torrance, CA 90505

Phone: (310) 257-1988

Fax: (310) 257-1897

Specialty: Dermatology

John Kennedy, M.D.

20911 Earl St., Ste. 200

Torrance, CA 90503

Phone: (310) 909-4851

Fax: (424) 257-8215

Specialty: Cardiology

Ali Morshedi-Meibodi, M.D.

20911 Earl St., Ste. 200

Torrance, CA 90503

Phone: (310) 214-3278

Fax: (310) 793-9000

Specialty: Cardiology

Retired

Ba N. Tran, M.D.

Specialty: Pediatrics

Resignation

Steven D. Barney, D.D.S.

Specialty: Oral Surgery

Keith R. Bayan, M.D.

Specialty: Pediatrics

Jessica Q. Zhou, M.D.

Specialty: Hospitalist

The Medical Staff Newsletter Progress Notes is published monthly

for the Medical Staff of Torrance Memorial Medical Center.

Thomas G. Simko, M.D.

Chief of Staff

Robin S. Camrin, CPMSM, CPCS

Vice President, Medical Staff Services & Performance Improvement

4


Medical Staff Services

3330 Lomita Boulevard

Torrance, CA 90505

Phone: (310) 517-4616

Fax: (310) 784-8777

www.TorranceMemorial.org

Mailing Label

ProgressNotes Vol. 4 Issue 10 October 2012

MONTHLY

MEDICAL

STAFF

NEWSLETTER

ProgressNotes

TORRANCE MEMORIAL MEDICAL CENTER

Torrance Memorial’s Planned New Patient Tower

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